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Consultation on Essential Public Health Functions with Australia, New Zealand and Pacific Island Countries, Nadi, Fiji, 8-11 December 2003 : report

31 décembre 2003 Organisation mondiale de la santé

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(WP)HSDII CPIHRF16.4/001 Report series number: RS/2003/GE/32(FIJ)

English only

REPORT CONSULTATION ON ESSENTIAL PUBLIC HEALTH FUNCTIONS WITH AUSTRALIA, NEW ZEALAND AND PACIFIC ISLAND COUNTRIES

Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Nadi, Fiji 8-11 December 2003

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines June 2004

WHO/WrIW L1:~!v\RY MANILA. PHILlPPlNES

NOTE

The views expressed in this report are those of the participants in the meeting and do not necessarily reflect the policy of the World Health Organization.

This report has been prepared by the World Health Organization Regional Office in the Westem Pacific for those who participated in the Consultation on Essential Public Health Functions with Australia, New Zealand and Pacific Island Countries which was held in Nadi, Fiji from 8 to 11 December ·2003.

CONTENTS

SUMMARY 1 1. INTRODUCTION ................................................................................................................ .4 1.1 1.2 1.3 1.4 2.5 2. Background infonnation ................................................................................................ 4 Objectives ..................................................................................................................... .4 Participants .................................................................................................................... 5 Organization .................................................................................................................. 5 Opening remarks ........................................................................................................... 6

PROCEEDINGS .................................................................................................................... 6 2.1 2.2 2.3 2.4 2.5 Objective one ................................................................................................................. 6 Objective two .............................................................................................................. 11 Objective three ............................................................................................................ 13 Objective four .............................................................................................................. 15 Public health competencies ......................................................................................... 18

RECOMMENDATIONS ..................................................................................................... 19 ANNEXES: ANNEX 1 - LIST OF PARTICIPANTS, TEMPORARY ADVISERS, REPRESENTATIVES/OBSERVERS, CONSULTANTS AND SECRETARIAT ANNEX 2 - PROGRAMME OF ACTIVITIES ANNEX 3 - LIST OF DOCUMENTS ANNEX 4 - OPENING SPEECH ANNEX 5 - INFORMATION PAPERS INF.l and INF.2

Keywords: Public health / Health planning / Health services / Health status / Research / Health promotion

SUMMARY

The consultation meeting on Essential Public Health Functions, with participants from Australia, New Zealand and Pacific island countries was conducted in Nadi, Fiji, from 8 to 11 December 2003 by the WHO Regional Office for the Western Pacific. The objectives of the meeting were: (1) to consider and discuss the nine proposed essential public health functions (EPHFs) developed for the Western Pacific Region, and the metll'lds used to evaluate the functions in the three case-study countries; (2) to identify the types of guidelines, tools and indicators, based on essential public health functions, that would be useful to assist Member States to evaluate, monitor and strengthen their public health infrastructures and responsibilities; (3) to identify approaches to promote the reorientation of health professionals, managers, policy-makers and government institutions towards public health, in line with the development of essential public health functions; and (4) to discuss ways in which essential public health functions can more clearly define and strengthen the central role of the ministry/department of health. The meeting was attended by 16 participants from Australia, Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Nauru, New Caledonia, New Zealand, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu. Observers attended from the Secretariat of the Pacific Community (SPC), the Vanuatu Ministry of Health (2) and Fiji School of Medicine (2). The meeting was supported by six WHO temporary advisers, one WHO consultant, and two WHO staff members serving as the secretariat. The proceedings comprised presentations reviewing the EPHF framework, case-study reports on experiences from the three-country study of EPHFs in the Western Pacific Region (Fiji, Malaysia and Viet Nam) and background papers addressing each of the four meeting objectives. Participants conducted small and large group discussions relating to pertinent issues and identified the recommendations from the meeting to further extend the use of EPHFs in the Pacific region. The meeting endorsed the concept of EPHFs as an excellenttool to strengthen public health in the region, acknowledging that there are current limitations on implementation (particularly with regard to resources). The following recommendations were made: Framework development: (I) Development and use of EPHFs at regional, country, provincial and programme levels should continue. Country-level development and application of the EPHF framework in the Pacific will require external resources (funding and technical assistiince). This could include examination by regional organizations and countries of the potential to redirect existing

(2)

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resources, approach multilateral and development partners, conduct bilateral negotiations and develop linkages with other institutions (e.g. academic, NGOs), to support further development and application of the EPHFs. (3) The EPHFs, tasks and practices should be further examined with respect to: • • • • emergency preparedness and disaster manageme.lt; terminology, to reflect the broader role in other sectors; suitability for audiences other than public health professionals; economic analysis in terms ofthe contribution of public health to the major priorities of the countries; research; and policies and laws that impact on public health,

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and the EPHF framework should be adjusted/modified accordingly if deficiencies are identified. Tools/guidelines/indicators: (4) Examples of applying the EPHF framework to progn•.. ,me-specific areas should be developed. Existing survey tools for EPHF assessment should be provided to countries upon request.

(5)

Regional: (6) Consideration of the EPHFs should be incorporated in the design, delivery and evaluation of future regional projects.

Reorienting health professionals and managers: (7) The EPHFs should be promoted as a basis for curriculum design and application in current and future health workforce development, training institutions and programmes of public health importance.

Spreading the concept: (8) Development partners, regional organizations and training institutions, in conjunction with Pacific countries, should develop and document case studies that apply the EPHFs, and illustrate potential gaps in public health and the consequences if they are not addressed. Development partners should expand the application of the EPHFs within their frameworks, assistance and activities.

(9)

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Country actions: (10) Appropriate application of the EPHFs should be promoted by engaging key stakeholders in-country (within the department/ministry of health and other ministriesINGOs, including reform projects). (11) The EPHFs should be utilized in plans for public health and the department/ministry of health. (12) Local expertise in using the EPHFs to define health workforce development requirements, including the identification of specialized public health training needs, should be developed. (13) Government support to enhance training on the EPHFs at all levels should be advocated. (14) Approaches and mechanisms to incorporate the consideration of EPHFs in current or proposed health-related reform projects should be identified.

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INTRODUCTION

1.1

Background information

Public health is a core element of every government's attempts to improve and promote health. Unfortunately, there is evidence that current public health systems and services struggle to cope with current demands. This problem applies to traditional public health areas, such as hygiene, sanitation and communicable disease control, and s~'. ('re acute respiratory syndrome (SARS) has been the most recent example demonstrating cha!\enges for developing, transitional and developed countries. This problem is also relevant in newer areas of public health, including the effects of globalization, migration and use of new technologies. Recognizing this, the WHO Western Pacific Regional Office has undertaken a project that involves the development of nine essential public health functions for the Region. They have been tested through application in three country case studies (Fiji, Malaysia and Viet Nam). The purpose of these functions is to assist Member States to define more clearly and systematically the core areas of public health work for which their governments are ultimately responsible. The broad concept of essential public health functions was discussed at the annual session ofthe Regional Committee for the Western Pacific in Kyoto, Japan, in September 2002. As a result of this discussion, the Regional Committee requested WHO to pursue further consultation and discussions with Member States and other relevant parties on the proposed essential public health functions, and to develop further the application ofthese functions. This meeting was organized as a key part of the response to that request. 1.2 Objectives The objectives of the meeting were: (1) to consider and discuss the nine proposed essential public health functions developed for the Western Pacific Region, and the methods used to evaluate the functions in the three case-study countries; (2) to identify the types of guidelines, tools and indicators, based on essential public health functions, that would be useful to assist Member States to evaluate, monitor and strengthen their public health infrastructures and responsibilities; to identify approaches to promote the reorientation of health professionals, (3) managers, policy-makers and government institutions towards public health, in line with the development of essential public health functions; and (4) to discuss ways in which essential public health functions can more clearly define and strengthen the central role of the ministry/department of health.

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1.3

Participants

The meeting was attended by 16 participants from Australi.l, Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Nauru, New Caledonia, New Zealand, Palau, Papua New Guinea, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu. Observers attended from the Secretariat of the Pacific Community (SPC), the Vanuatu Ministry of Health (2) and Fiji School of Medicine (2). The meeting was supported by six WHO temporary advisers, one WHO consultant and two WHO staff members serving as the secretariat. A list of participants, representatives, temporary advisers and secretariat members is given in Annex I. 1.4 Organ iza ti on

The workshop programme is given in Annex 2 and a list of documents distributed during the workshop in Annex 3. The documents included reports on the implementation of the EPHFs in the previous three-country study and background papers by the temporary advisers and WHO secretariat members relating to each of the four meeting objectives. Copies of the first two background papers are included in Annex 5; copies of other papers can be obtained upon request from the WHO Regional Office for the Western Pacific. The officers of the workshop were elected as follows: Chairperson Vice- Chairperson Rapporteurs Dr Jefferson Benjamin, Federated States of Micronesia Dr Josaia Samuela, Fiji Dr Airambiata Metai, Kiribati and Dr Sylvie Barny, New Caledonia

The technical sessions of the meeting started with a review of the EPHFs, based on background paper one and case-study reports from Malaysia, Viet Nam and Fiji summarizing the methodologies used, results obtained and application of results to strengthen public health capacity. These presentations and the plenary that followed addressed the first objective of the workshop. Background paper two was presented, with participants being divided into three groups to discuss selected key questions that would provide guidance in assessing the requirements for tools, guidelines and indicators to assist in applying the EPHF concept. The groups were then reconvened for a plenary session regarding the results. These actions addressed the second objective of the workshop. The session focusing on public health workforce development issues as a component of the reorientation process commenced with a presentation based on background paper three. A large group discussion on pertinent issues was then undertaken. This presentation and the plenary that followed addressed the third objective of the workshop. A presentation on the role of ministries of health was provided, based on background paper four and incorporating two group activities to examine the perceived strength of relationships with other stakeholders and the major national challenges that will be likely to impact on countries in years to come. The participants were divided into the same three groups as previously utilized to undertake group sessions. Both group sessions were followed by a

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plenary to coalesce the results. A further presentation and large group discussion on managing for outcomes and developing trust as key components to implementing the EPHFs was conducted. These presentations, group and plenary sessions addressed the fourth objective ofthe workshop. A large group discussion on competencies in public health was conducted based on the results of the preceding sessions. Following this, the recommendations emanating from the meeting were prepared, discussed and adopted by the participants at the closing session. 2.5 Opening remarks

The Honourable Mr Solomoni Naivalu, Minister of Health, Fiji, welcomed participants. He indicated that the meeting had been convened based on the recommendation of the WHO Regional Committee Meeting in Kyoto in 2002, which called for additional discussion on the implementation of the EPHFs in the Western Pacific Region. He said that the meeting was timely and would build on a long history of actions to enhance health, with the recent 25 th anniversary of the Alma Ata Declaration signing, the Health For All initiative and, more recently, the Millennium Development Goals. He stressed that governments had a key role to play in the process. In Fiji, this is exemplified by the use of the findings from the earlier threecountry study utilizing the EPHFs. The data have been used strategically to inform the current health reform project, realign the budget allocation to primary health and preventive services (particularly in rural areas) and extend training in public health, with a view to enhancing staff skills and retention. He expressed his appreciation to WHO for the continued support in this important area and welcomed all participants to Fiji, hoping that they would have fruitful deliberations during the meeting. On behalf of Dr Shigeru Omi, WHO Regional Director for the Western Pacific, Dr Ken Chen, WHO Representative in the South Pacific, delivered an opening speech. He thanked the participants for their attendance at the important meeting. He suggested that public health was a core element that required government involvement and that WHO was seeking to collaborate pro-actively with Member States on the issue. The concept of the EPHFs provides a solid background upon which to further stimulate ideas on what can enhance public health actions in countries. The World Health Report 2003, entitled Shaping the Future, has a strong public health focus and re-emphasises WHO's acknowledgement of this as a key area. He noted that this meeting was aiming to consider four objectives to further develop the methods and utilization of the EPHFs. Thanking the Fiji Government br hosting the workshop, Dr Chen officially opened the meeting and concluded his opening remarkS. The full text of the opening speech is given in Annex 4. 2. PROCEEDINGS

2.1

Objective one To consider and discuss the nine proposed essential public health functions developed for the Western Pacific Region, and the methods used to evaluate the functions in the three case-study countries.

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Dr Graham Harrison, WHO Regional Adviser in Health Systems Development, introduced the EPHFs by providing background detail (two background papers, INF.1 and INF.2, refer Annex 5) on some of the issues impacting on public health, including current demands on infrastructure, emerging diseases / health problems, and changes in demographic and epidemiological patterns. While there are also many health refonns in progress, they tend to focus on management and clinical treatment perspectives, with little consideration of public health per se. As such, the EPHFs aim to provide a concept upon which public health can be described in both a comprehensive and practical manner. While there are many definitions of public health, they do not reflect ways to improve performance and hence health outcomes. These definitions/descriptions are also very general, and do not help governments to understand what should be } l.>vided with respect to public health. The EPHF framework attempts to align the core business of public health, public health outcomes and preventive and clinical services, with optimal public health delivery, and provide a more concrete definition/description of key public health activities in a more generic sense, rather than this becoming just a long list of specific services. The framework consists of nine functions, with each function being further divided into key tasks and then specific practices. In tum, the performance of these tasks and practices results in outputs (programmes and services), intended to improve health status. The nine functions, related tasks and practices are described in Annex 5. The context in which the EPHFs can be operationalized is influenced by: governance and stewardship issues (e.g. leadership and strategic goals); the multidimensional nature of the framework, which results in not all functions/tasks/practices being required at all levels of a public health system; the intersectoral nature of the actions required; and critical links and relationships with other key organizations/services in the delivery of public health, (e.g. personal preventive and treatment services, other sectors, communities and academic institutions). While the EPHF framework is comprehensive, there are components that are intentionally excluded. For example, diagnostic and clinical services that are not related to treating diseases of public health significance, and the overall policies/mechanisms for public health financing, are not included. However, each country determines which diseases are considered as being of public health significance, thereby providing some flexibility in detennining what is relevant in a country context. While governments need to ensure the provision of EPHFs, these can be funded and provided through various means. However, as the EPHFs are mainly public goods, government will inevitably be called on to finance many aspects of the functions. In evaluating the current status of public health services, the EPHF framework can be used at three levels in assessing: • specific practices based on national health goals; • practices within programme areas, e.g. Environmental Health and Communicable Disease Control; and • practices in other areas of health care and/or other organizations with a role in public health.

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The link between primary health care (PHC) and the EPHFs was discussed. It was explained that, while PHC is important for implementing many EPHFs and their tasks, PHC does not necessarily encompass all aspects of public health.

In implementing the EPHF framework, the department/ministry of health plays a number of key roles including: being the government's key adviser on health; taking the lead in ensuring the provision and effectiveness of all EPHFs, including those outside the health sector; working with and advising others on strengthening gaps/weaknesses in the EPHFs; and advising on the EPHFs during reforms both within and outside the health sector. A large group discussion followed and raised issues principally within four domains. (1)

Linking the EPHFs with the concepts of Healthy Islands and PHC

As many of the existing public health services throughout the participating countries are modelled on one or both of these approaches, it was seen as important that efforts be made to illustrate clearly how they interrelate with the EPHF framework. This would assist with the ease of introducing the EPHF framework as a tool for use in countries. (2) Capacity of Pacific health services to adopt the EPHFs

As Pacific health services are limited in size and tend to cover both clinical and preventive perspectives, separation of these two components may prove problematic. A question was raised as to whether a similar approach to the EPHFs was available, covering health services in total (clinical and preventive). While it was noted that there were many clinical guidelines available, no such system was knO\'l to exist. It was highlighted that countries would require assistance to ensure both clinical and preventive issues were covered. In response to this issue, it was highlighted that the EPHF framework in itself does cover a number of aspects of direct relevance to clinical services. Not only does it enable country-specific interpretation of clinical services to treat diseases of public health significance, but it also includes the broader framework that encompasses allocation of public resources within the health sector and governance of the activities of clinical services, such as the setting of regulatory standard-setting frameworks, the regulation of health professionals, and the monitoring of access to clinical services by different population groups. (3) Changes to terminology in the framework

While the EPHF framework can potentially provide a common language across sectors, it may require terminology modifications to better reflect the Pacific context and make it more easily understood in other sectors. For example, it was suggested that the term "health service policy" be replaced by the more generic term "healthy public policy", thereby acknowledging the broader intersectoral policy modifications required. This is an aspect that requires further analysis. (4) Health as an economic asset for country development

It is becoming increasingly important to demonstrate that the public health sector is not a drain on the resources of a country and that there are significant economic benefits from having a healthy population. This is particularly important for the debates that

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happen within the government sector, particularly wi.( resources are being allocated. It was believed that the use of the EPHF framework could assist with this process as future economic analyses of public health interventions are completed, but this aspect may need to be more prominent within the framework. The presentations of the three country case studies commenced with a summary of the background to developing the EPHFs by Dr Harrison. A meeting of the three country representatives was convened and assessed instruments previously used in other settings (including work by the Pan American Health Organization and United States CDC). Based on this assessment, the EPHF framework for the Western Pacific Region was developed. The specific methodology employed in each country was defined on country needs and constrained by the resources and time that could be contributed to the programme. A common methodological feature was the establishment of a Programme Advisory Group, involving very senior people, to oversee progress in each country. Similarly, all case study countries utilized a systemized approach consisting of three steps: (1) a situational analysis; (2) a SWOT analysis; and (3) development of options for strengthening public health and a review of these in light of future changes/threats. Malaysia Dr Safurah laafar, WHO temporary adviser, introduced the Malaysian case study, indicating that they are now using the EPHFs as a concept to improve public health. The research had been undertaken through the Ministry of Health, with the methodology being qualitative in nature, using a series of three workshops. The first workshop had utilized key informants to look at the core business of public health and identify existing gaps. The second workshop had completed a SWOT analysis against the Ministry of Health guidelines and national health plan. From this analysis, three proposals had been developed and tested in the final workshop against the potential threats of centralization, decentralization and privatization to ensure the EPHFs were not compromised. It was perceived that the use of the EPHFs had resulted in some significant benefits. First, it had developed a common language across groups from government, private, NGO and local authorities. Second, EPHFs had been adopted by the Ministry of Health and universities as a basis for formal recognition of public health medicine specialists. Third, a new unit for legislation and enforcement within the Ministry of Health had been created as a result of the EPHF work.

VietNam Dr Vu Xuan Phu, WHO temporary adviser, introduced the Viet Nam study, providing an overview of the country profile and the organizational structure of the health care system. The EPHF programme had been undertaken through the Ha Noi School of Public Health, using a multidisciplinary team with a strong PHC focus. A local advisory group, headed by the Minister of Health, had been established. The methodology had included a random selection of four provinces, based on population size, geography (urban/rural) and district/commune level. Data had been obtained from a number of sources including: census data and government reports; key informant interviews at different levels of the health service; interviews and group discussions of key informants; and

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review of the laws and databases relating to areas mandated to public health. A comprehensive summary of the findings was provided. Fiji Dr David Phillips, WHO temporary adviser, introduced the Fiji study with an overview of the project, including field-testing of the process to reflect local information and application. It was highlighted that the analysis had only gone as far as assessing tasks, due to the difficulty in going beyond this to practices. The programme had been undertaken through the Fiji School of Medicine and the Ministry of Health. The methodology had been strongly influenced by internal issues within Fiji, as the period of assessment was immediately following the coup. This had resulted in the use of purposive sampling, with data being largely collected from the vicinity of Suva and surrounding areas. The methodology had employed a range of pragmatic approaches in attempting to assess all different levels of the system. Methods had included semi-structured, individual, large-group and specific focus-group interviews. Additional methods had incorporated local community discussions on the perceptions of how public health services/activities were being implemented and a self-assessed measure on activities and competence. A summary of the findings was provided. Perceived benefits arising from involvement in the process were many, including: enabling wide-ranging discussion; improving understanding of core functions; acting as a basis for discussion in the health reform process; developing local investigative skills; identifying areas for competency development; promoting a shared understanding to protect and strengthen action; and highlighting methods to improve delivery of the EPHFs. Dr Lepani Waqatakirewa, WHO temporary adviser, outlined how the results had been utilized by applying the EPHF framework to an existing intervention. It was suggested that action needed to be in line with core business, be a proven evidence-based public health intervention and be identified as a national health priority. The issue of tobacco control was assessed in relation to a number of functions and key tasks that are required to apply successful interventions. From this example, it was evident that the framework could provide a sound platform upon which public health interventions could be determined. However, the order of assessment, strength and progress on the implementation of EPHFs may vary, as could achievement of outcomes. A large group discussion followed and concentrated on two major issues: (1) Clarification ofthe EPHFs

The EPHFs were summarized as a tool that could be used in any way that suited a country and assisted with improving public health. This could include work within the health system, but also with partners from other sectors - villages, traditional leaders, churches, NGOs and other government departments. The EPHF framework/tool may need refining, but it needs to be used and tested further in the Pacific context to decide how it can be improved.

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(2)

Barriers to use of the EPHFs

Identifying the development mechanisms that could be used to progress utilization of the EPHFs following the meeting was highlighted. Indeed, it was indicated that the meeting was an initial step towards ongoing collaboration to ensure its continuity. Additionally, finance/resource issues for public health were discussed as a potential threat limiting the expansion of the EPHFs. 2.2 Objective two To identify the types of guidelines, tools and indicators, based on essential public health functions, that would be useful to assist Member States to evaluate, monitor and strengthen their public health infrastructures and responsibilities. Dr Tony Lower, WHO meeting consultant, presented a summary of the background paper INF.3, outlining the importance of evaluating and monitoring so that public health systems can be more fully understood and enhanced. While the full evaluation of the EPHFs was identified as a complex task, it was imperative that key stakeholders be involved in the process, with such collaboration being even more important in cases where there are limited resources. As the EPHFs are a new concept in the Pacific region, they will require leadership from within the ministry/department of health and also the support of senior staff. Consequently, a clear understanding of the EPHFs by these groups is vital. When evaluating any system, inevitably information on strengths and weaknesses is collected. The purpose of collecting these data must be well understood by stakeholders, must never be seen as a test of the service or staff, and the resulting information should not be used negatively against staff. Other important aspects of evaluating the EPHFs were the recognition that all public health systems have weaknesses and that thcr:.- Jhould be realistic expectations about what is possible given resource limits. The advantages and disadvantages of a range of evaluation methods (checklists, documentation analysis, individual interviews and focus groups) were outlined. As it may not be practical or feasible to assess all of the EPHFs at anyone point in time, some subjective criteria to assist in identifying the priority order in which functions could be assessed were described. These included: assessing the perceived population health impact of the different functions; determining the highest cost-benefits for the community and government; identifying the existing data sources that could be useful; rating the quality of performance in each function; and listing the available financial and human resources available. Participants were split into three groups and assigned one specific question and one for all groups to consider. Responses from each group were provided back to the large group. allowing for additional discussion. The first group's task was to identify key stakeholders and determine how they could be engaged. Stakeholders that were classified as internal to the department/ministry of health included: senior executives, middle-level managers, programme supervisors, clinical providers and field workers. External stakeholders included: NGO representatives (both in-country and international); other government ministries; public services; training institutions; political leaders; the media; child, welfare and women's groups; development partners; and community representatives, such as traditional and church leaders. To engage these stakeholders, approaches, such as interviews regarding public health knowledge.

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workshops/open forums, identifying programmes that already exist in the community, utilizing the media, and running community competitions, were su,' :ted. The second group addressed the issue of how health reform could contribute to the evaluation and monitoring of the EPHFs. It was perceived that the EPHFs could be used with strategic and business plans to improve performance and to advocate for an increase in the budget allocations to public health. An additional approach was the extension of the EPHFs to form the basis of the nurse-training curriculum. It was noted that, while health reforms are big projects, they are largely concerned with structure and budget issues in first instance and do not permeate to the concerns of field workers. Despite this focus, it was felt that reforms could in fact benefit from the use ofthe EPHFs as an approach to systematically improve public health, address the concerns of field workers, and also improve structural and budgetary arrangements overall. Group three discussed the merits of introducing a checklist system to assist in strengthening (evaluating/monitoring) the EPHFs. It was agreed that a checklist system (as used in the Public Health in the Americas initiative), could be useful in assessing staff capabilities/capacity, determining the level of public health delivery at a programme or intervention level, and in writing proposals. However, as checklists tend to be selective and measure outputs and not impacts, their utility was not perceived as high. In general, there was limited support for a checklist approach and, if it was to be utilized, it would need to be modified or supplemented with broader questions on the quality and quantity of public health services to give more depth to the information. The final question addressed by all groups, centred on the perceived current strengths and weaknesses of the public health system in the participating countries. Strengths identified included: high levels of community involvement (partly as a result of the existing chief/communal structure) making it easier for implementation of interventions; highly committed staff; and the attractiveness of public health issues to the media. The major weakness was the perception of less than optimal partnerships across sectors. To address this issue it was considered imperative that countries had strong leaders at ministerial level advocating for public health. It was also highlighted by one participant that the meetbg was one of the few opportunities that public health leaders in the Pacific had had to discuss public health issues in general, as opposed to other specific issues, like communicable disease. Presentation of background paper two recommenced and focused on the final component of the objective in strengthening public health based on the results of the evaluation and monitoring of the EPHFs. Six preconditions for strengthening were identified and discussed, as outlined below: (1)

A public health mandate in government with relevant legislation and policy Adequate financial resources for public goods Multidisciplinary workforce with adequate numbers and skills Good public health leadership and management. Dedicated resources with accountability systems

(2) (3) (4) (5)

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(6)

Supportive health sector regulation.

A large group discussion was conducted to determine if the EPHFs could be useful in obtaining additional resources to strengthen public health. The participants felt that the EPHFs added structure to public health and could definitely assist with strengthening training, funding, evaluation and defining the necessary skills for staff. Overall, it was perceived that the EPHFs offer a sectorwide approach, would provide new "energy" to examine public health in the Pacific, and would allow for within and between-country comparisons. However, additional analysis with more focus from a Pacific perspective was needed for the current EPHF framework - for example, whether emergency preparedness and disaster management should be a separate function, and whether the language should be changed to make it more user-friendly, particularly for use with other non-health sectors. Additionally, the provision of direct examples that could be used as advocacy tools using the EPHFs to define current gaps and what the implications might be if no action is taken, was suggested. The lack of skilled health management to assist with ;.,;,plementing the EPHFs, where people not trained in management end up in management positions, was also discussed. It was indicated that assisting practitioners moving to management positions with suitable ongoing training was required. Furthermore, the futility of project funding that does not have a sustainability component embedded within it was raised. This may be partly addressed by using the EPHFs to advance the concept of public health to funding agencies. Expanding links with the New Zealand Agency for International Development (NZAID)/Australian Agency for International Development (AusAID) around EPHFs was encouraged. 2.3 Objective three To identify approaches to promote the reorientation of health professionals, managers, policy-makers and government institutions towards public health, in line with the development of essential public health functions. Dr David Phillips, WHO temporary adviser, provided a summary of background paper INFA, applying the EPHFs to the issue of public health workforce development. While barriers to strengthening the public health workforce may exist, it was evident that human resources were an essential part of the necessary infrastructure. Without an effectively functioning health workforce (function 6), it would be impossible to attend to the other functions within the EPHF framework. The use of the EPHFs as the basis for public health workforce development, was predicated on the following four points: (1) (2) (3) (4) It can link to and be based on, the required public health competencies. It provides for the coordinated development of the public health workforce. It can include frameworks for certification and accreditation of staff. It will assist in reorienting and improving the quality of training.

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A number of key features that relate to the use of the EPHFs in public health workforce development were defined. These included: establishing stronger partnerships across sectors; introducing a variety of methods for training at different levels of the health system; recognizing that health workers have several roles/careers and attempting to cater for those issues; developing training based on adult learning principles and the required competencies; and understanding that by enhancing individual competencies you can improve organizational development. Overall, it was felt that the EPHFs could assist with defining training needs, programme development, training content, delivery and evaluation for workforce development. However, while the EPHFs can serve as a unifying concept for workforce development, it will require significant commitment within countries. A large group discussion was conducted, reviewing workforce issues. While support for the EPHFs as a good approach was forthcoming, it was noted that the skills required to implement the functions would inevitably vary at different levels in the health service and for different professional groups. Additional work is required to examine what tasks relate to specific positions within the hierarchy of each health service and then identify the relevant competencies. While it is difficult to identify what specific workforce development training is required without a human resources plan, the current reality is that staff returning from training end up doing a range of tasks, not just what they have focused.on in their training. Therefore, it is good to have one person who specializes in an area as a resource person, but who is also multi-skilled. Further, it is important that, not only are the right skills transferred, but that the right mix of personnel is available. From this perspective, it would also be useful to include NGOs as partners in training. Consequently, workforce development needs to be gradated, starting with access to basic material and slowly developing through to a post-graduate level. The EPHFs could be used by countries to define their needs and by training institutions to specify the skills that students will attain in completing the curriculum. The emphasis on workforce training in public health should maintain a population focus and not a clinical one. However, each country win also have specialization requirements for public health training that need to be identified and upon which ~aining can be based on incountry problems/issues. There was a clear preference for in-country training, as it was deemed to be cost-effective in terms of human and financial resources, and could be managed locally to meet specific country requirements. A quality issue that arose was that such training was frequently not linked to a formal qualification and there was often no assessment to define if learning had occurred. Potentially, the newly developed WHO Open Learning laboratories are an opportunity to address these issues by improving relationships with training institutions and to introduce the EPHF framework. The inclusion of public health workforce development into the health reform process was highlighted as being important to the longer-term incorporation of the EPHFs. While the problem of staff retention, particularly for those receiving post-graduate training, was raised, ways to resolve this issue were unclear.

- IS -

Resource allocation to ensure effective workforce development in line with the EPHFs was discussed at length. Currently, although resources are limited, further investigation of how the Pacific information can be aligned with the WHO assessment of global human resource development and planning issues was required. Additiom(' ,World Bank interest in the work of P AHO and others in the United States and the Americas has been positive and further discussion with this group may be beneficial. A suggestion was also made that workforce development using the EPHF framework could be run on a trial basis in alignment with an existing vertical programme, e.g. tobacco, therefore, not requiring additional resources of any significant magnitude. Similarly, the nature of the assessment could vary, as has been the case with the recent quick assessment of public health in Samoa over a two-week period in conjunction with the Fiji School of Medicine. 2.4 Objective four To discuss ways in which essential public health functions can more clearly define and strengthen the central role of the ministry/department of health. Dr Gillian Durham, WHO temporary adviser, commenced the presentation with a discussion reinforcing the central role ofthe department/ministry of health with respect to public health as a designated public good (background information paper INF.5). However, it is clear that other agencies/organizations also influence public health and, consequently, good relationships are important to achieving public health outcomes. This was followed by the illustration of a model that could be used to define the extent to which key public health stakeholders perceive public health as being a central role of the department/ministry of health (government, the department/ministry of health itself, the public, development partners, health sector, TreasurylFinance). The roles of the department/ministry of health, drawing on examples from Fiji, Malaysia and Viet Nam, were provided and discussed. Participants reflected similar roles in their countries. However, it was suggested that an additional role is the coordination of development partner funding. Dr Lepani Waqatakirewa then presented a summary of the way in which the identified weaknesses in the role of the Ministry of Health in Fiji had been progressed since the study in the areas of leadership, programme funding, resource allocation, donor funding, information systems and legislation. Participants reconvened into three small groups and completed the conceptual model examining perceived roles in public health. This was completed on an individual basis and then aggregated responses were compiled. Each group was also asked to note specific limitations to the role of the department/ministry of health in respect to public health, including legislation, mission/goals, convention/policy and any other issues, excluding resource limitations. Reports by group representatives indicated some similarities but also significant variation in the perception of various stakeholders on the central rok of the department/ministry of health in public health. A range of factors limiting the public he&t-th role of departments/ministries of health were noted. These included: (1)

Legislation • There is a requirement for enhanced political will and commitment to legislative development and modifications.

- 16 -

• •

Existing laws need updating and there are often significant delays in processing legislation. Enforcement of existing and new legislation is often not possible. Changes in social issues such as civil unrest also impact negatively on legislative development.

• (2)

Mission/Goals • They are sometimes not specified or are unrealistic.

(3)

Convention/policy • The pace of change and introduction has been too rapid to keep pace with. The perception is that there are too many conventions and that, just when Ministries are coming to terms with one, another new one is superimposed. Process often results in either failure to implement or implementation failure. Development partners are often inflexible on these issues adding to difficulties.Other issues Inadequate number of staff with suitable skill sets. Poor allocation of funds to public health.

• •

In summary, it was perceived that improvements in the recognition of public health as a central role of the department/ministry of health would be beneficial. The use of the EPHF framework may provide a tool by which the central role of the department/ministry of health can be further developed and recognized, thereby also extending linkages with other stakeholders to improve health outcomes. The presentation recommenced, detailing how health is frequently not considered a priority issue by governments and thus the importance of identifying approaches that demonstrate the critical role that public health has with country development more broadly. The framework of the "Seven Revolutions" was introduced and examples discussed - population, hyper-urbanization, resources, technology, information, time and distance, war and conflict. In the publication from which these were drawn, these 'revolutions' were seen as potential big picture issues that would influence government thinking on a strategic level for the next 20 -30 years in the United States of America. Conceptually, it is useful to think about the 'revolutions' that will be relevant to the future of each country, so that public health can work to demonstrate its interrelationship with each of these and thus get a better place on government agendas. A hypothetical example, incorporating a matrix with the EPHFs, was used to illustrate these relationships, with the EPHFs being clearly linked to numerous issues.

- 17 -

Participants returned to their groups to investigate two questions: (l) (2) What are the "seven revolutions" your countries are facing? How could we use the EPHFs to help you address those issues?

The group spokespersons identified a number of significant issues that either currently are and/or potentially will be issues of national significance for their countries, these being: population/demographic changes; urban migration; resources; technology; globalization; social and economic inequalities; climate/environment; emerging and re-emerging diseases; NCDs; economy; water; food security; natural disasters; war and conflict; and suicide. The group then discussed examples of how the EPHFs could be articulated with the revolutions identified, and how such a process might be useful in ensuring public health is considered a key government priority into the future. Dr Durham recommenced the presentation, outlining a focus on improved health outcomes and "Doing the Right Things Right". A summary of the three types of reform undertaken in the health sector was provided - structural, process and managing for outcome reforms. While structural reforms largely focus on management systems, process reforms deal with modernization and governance issues. Process reforms are frequently based on five simple rules: seeing things through patients' eyes; finding a better way of doing things; looking at the whole picture; giving front-line staff the time and the tools to tackle the problems; and taking small steps as well as big leaps. A significant part of process reform is managing the resistance to change, with the formula emphasizing prerequisites for change being: - Dissatisfaction x vision x capacity x first steps> Resistance In this formula, all elements must be adequately addressed to overcome resistance and ensure the reform progresses effectively.

The most important reform process from a public health perspective is managing for outcomes. In this respect, a systematic approach incorporating reviewing the evidence, selecting a few vital outcomes, selecting evidence-based interventions to address these outcomes, identifying and assessing threats, monitoring and evaluating the process, building local capacity, reviewing progress and adjusting plans, was advocated. An example of how this system of managing for outcomes could be applied with the EPHFs was illustrated. Another important issue to enhance the role of the department/ministry of health in public health and its capacity to work with other key public health stakeholders, is the perception of trust that the stakeholders have in the department/ministry of health. When an organization is trusted it is "recognized for doing the right things right", with levels of trust rising as the perceived competency and caring of an organization increases. As a component of building trust by illustrating competence, it is imperative that effective measurement procedures be implemented, as what gets measured gets done and, if you can demonstrate results, you can win public support. Additionally, the process of benchmarking and establishing relevant standards can assist in developing competence. Finally, a summary of how the competence and caring factors could relate to the EPHFs was provided.

- 18 -

A large group discussion followed, supporting the use of the EPHFs as a tool to help strengthen public health. However, concerns were raised as to the opportunity to apply this concept due to financial and human resource constraints. Suggestions included further meetings to produce instruments or the adoption of the EPHFs within existing vertical programmes prior to implementation more broadly. The participants were looking to WHO for leadership and assistance in commencing preliminary work with the EPHF r '~nework. Several other suggestions were made including: using the EPHFs as a benchmarking tool within and between countries; utilizing the EPHFs in planning processes, including current or proposed reform projects; further developing potential methods that countries could utilize; providing opportunities to use the tools; identifying approaches to develop local expertise in using the EPHFs; and including the EPHFs as a basis for health curriculum development. 2.5 Public health competencies

Dr Graham Harrison, WHO Regional Adviser in Health Systems Development, led a large group discussion on the issue of competencies. A range of issues was raised by participants and are summarized below. Competencies at both individual and organizational levels are important, as it is perceived that improvements in individual competencies translate into practice, improved organizational competence and then better health outcomes. Countries should resolve what competencies people at different levels ofthe health system need and then relate these to the EPHF framework. This information can then be provided to training institutions to ensure training matches the necessary country needs. In general, although in-country training is preferred, there is a lack of existing skilled staff to implement this training in specific areas. Consequently, the identification of mechanisms to facilitate in-country training would be useful. Many of the competencies required at the department/ministry of health level to implement the EPHFs are simply not available at the country level. Even in countries undergoing reform, there have been significant staff retention issues, thereby reducing the number of available people with suitable competencies. Two suggested issues to examine here are the parity of pay scales and ensuring academics are actively engaged in research while teaching. The forthcoming World Health Report 2003 highlights the human resource implications of the global public health worker crisis. This will hopefully mean an increase in the future allocation of resources to this area within WHO, although this may not start to occur until 2006-2007, as the 2004-20005 funding allocations have already been approved by the World Health Assembly (WHA). At a regional level, the WHO budget has been reduced substantially in the past three years, relating to an earlier WHA decision i" favour of shifting resources to some other WHO regions, making it more difficult to provi:\{: resources for more general areas of strengthening public health, as much of the resource is still directed through programme-specific activities. However, while resources are limited, WHO will seek to progress actions in conjunction with other stakeholders. One possible mechanism for increasing resources to strengthen public health is for countries to examine reallocation of resources within their WHO country budgets.

- 19 -

WHO will develop an example of a matrix for two or three vertical programmes that identifies the way in which the EPHFs can be applied to specific programme areas. It was proposed that potential examples could be communicable disease control, food safety, emergency management and disaster response. These could be made to incorporate two levels of activity - policy (central department/ministry) and local operational level application. Where competencies already exist in certain professional disciplines, it would be good to share these between countries as a starting point for further development. There are significant human resource issues in relation to the development of legislation. In particular, the issue of drafting initial instructions to guide legislative reviews was highlighted. WHO agreed to examine if there were any generic guidelines that could assist countries in drafting legislative instructions.

RECOMMENDATIONS

The meeting endorsed the concept of EPHFs as an e"l("':llent tool to strengthen public health in the region, acknowledging that there are current lilllitations on implementation (particularly with regard to resources). The following recommendations were made: Framework development: (1) Development and use of EPHFs at regional, country, provincial and programme levels should continue. Country-level development and application of the EPHF framework in the Pacific will require external resources (funding and technical assistance). This could include examination by regional organizations and countries of the potential to redirect existing resources, approach multilateral and development partners, conduct bilateral negotiations and develop linkages with other institutions (e.g. academic, NGOs), to support further development and application of the EPHFs. The EPHFs, tasks and practices should be further examined with respect to: • • • • emergency preparedness and disaster management; terminology, to reflect the broader role in other sectors; suitability for audiences other than public health professionals; economic analysis in terms of the contribution of public health to the major priorities of the countries; research; and policies and laws that impact on public health,

(2)

(3)

• •

- 20-

and the EPHF framework should be adjusted/modified accordingly if deficiencies are identified. Tools/guidelines/indicators: (4) Examples of applying the EPHF framework to programme-specific areas should be developed. Existing survey tools for EPHF assessment should be provided to countries upon request.

(5)

Regional: (6) Consideration of the EPHFs should be incorporated in the design, delivery and evaluation of future regional projects.

Spreading the concept: (8) Development partners, regional organizations and training institutions, in conjunction with Pacific countries, should develop and document case studies that apply the EPHFs, and illustrate potential gaps in public health and the consequences if they are not addressed. Development partners should expand the application ofthe EPHFs within their frameworks, assistance and activities.

(9)

Country actions: (10) Appropriate application of the EPHFs should be promo:.:J by engaging key stakeholders in-country (within the department/ministry of health and other ministrieslNGOs, including reform projects). (11) The EPHFs should be utilized in plans for public health and the department/ministry of health. (12) Local expertise in using the EPHFs to define health workforce development requirements, including the identification of specialized public health training needs, should be developed. (13) Government support to enhance training on the EPHFs at alllevels should be advocated. (14) Approaches and mechanisms to incorporate the consideration of EPHFs in current or proposed health-related reform projects should be identified.

ANNEX I

WORLD

HEALTH

ORGANIZATION

ORGANISATION MONDIALE DE LA SANT~

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R£GIONAL DU PACIAQUE OCCIDENTAL

CONSULTATION ON ESSENTIAL PUBLIC HEALTH FUNCTIONS WITH AUSTRALIA, NEW ZEALAND AND PACIFIC ISLAND COUNTRIES Nadi, Fiji

WPRlICP/HRF/6.4/001/HSD(I)12003IIB12 2 December 2003

ENGLISH ONLY

8 to 11 December 2003

INFORMATION BULLETIN NO.2 PROVISIONAL LIST OF PARTICIPANTS, TEMPORARY ADVISERS, REPRESENTATIVES/OBSERVERS AND SECRETARIAT

1. PARTICIPANTS

AUSTRALIA

Ms Marion Dunlop Assistant Secretary Population Health Division Commonwealth Department of Health and Ageing GPO Box 9848 Canberra, ACT 260 I Tel. No.: +61262877035 Fax No.: +61262898483 Email: Marion.Dunlop@health.gov.au

COOK ISLANDS

Ms Natalie Ngapoko Short Director of Public Health Ministry of Health P.O. Box 109 Rarotonga Tel. No.: +682 22757

WPRlICP/HRF/6.4/001/HSD(1)/2003IIB/2

Page 2

FIJI

Dr Josaia Samuela Acting Chief Medical Officer (Community Health) Divisional Health Office Ministry of Health P.O. Box 104 Labasa Tel. No.: +6798812522 Email: jsamuela@yahoo.com Dr Airambiata Metai Director Public Health Services Ministry of Health and Medical Services P.O. Box 268 Bikenibeu Tarawa Tel. No.: +68628493 Fax No.: +68628152 Email: mhfp@tskl.net.ki Dr Jefferson B. Benjamin Secretary Department of Health, Educalion and Social Affairs Federated States of Micronesia P.O. Box PS 70 Palikir Pohnpei FM 96941 Tel. No.: +6913202619 Fax No.: +691 3205263 Email: Jeffb@mail.fm Dr Godfrey Waidubu Acting Director of Public Health Ron Hospital Tel. No.: +6744443883 Fax No.: +6744443883 Email: godwaid@hotmail.com Dr Sylvie Barny Epidemiologist and Public Health Physician Health Activities Section Department of Health and Social Affairs B.P .N4-98851 Noumea Cedex Tel. No.: +687243715 Fax No.: +687243702 Email: sbamy@gouv.nc

KIRIBATI

MICRONESIA, FEDERATED STATES OF

NAURU, REPUBLIC OF

NEW CALEDONIA

WPRlICP/HRF/6.4/00llHSD(I)/20D3/IB/2 Page 3

NEW ZEALAND

Ms Margaret McGregor Development Manager - Public Health Ministry of Health Private Mail aag 92522 Wellesley Street Auckland Tel. No.: +6495809114 Fax No.: +6495809001 Email: maggie_mcgregor@moh.govt.nz

PALAU, REPUBLIC OF

Dr Janice Ngirasowei Manager Central Community Health Center Ministry of Health P.O. Box 6027 Koror Tel. No.: +680 488 2552 Fax No.: +6804881211 Email: ngirasowei@yahoo.com

PAPUA NEW GUINEA

Dr Timothy Pyakalyia Deputy Secretary Department of Health P.O. Box 807 National Capital District Waigani Tel. No.: +675301 3775 Fax No.: +675 301 3604 Email: pyakalyia@health.gov.pg

SAMOA

Dr Saine A1ova'ai Public Health Medical Officer Communicable Disease Control Ministry of Health Private Mail Bag Apia Tel. No.: +685 77507 Email: sainea@health.gov.ws sainealo@hotmail.com

SOLOMON ISLANDS

Dr George Malefoasi Undersecretary for Health Care Ministry of Health P.O. Box 349 Honiara Tel. No.: +677 24097 Fax No.: +677 20085 Email: ushc@solomon.com.sb

WPRlICPIHRF16.4/001IHSD(1 )/2003llB/2 Page 4

TOKELAU

Dr Tekie losera Director of Health Tokelau Apia Liaison Office Apia Tel. No.: +685 20822 Fax No.: +68521761 Email: director .health@c\ear.net.nz Dr Malakai 'Ake Chief Medical Officer Public Health Division Ministry of Health P.O. Box 59 Nuku'alofa Tel. No.: +67623 200 Fax No.: +67624291 Email: drmalakai@hotmail.com Dr Nese Ituaso-Conway Acting Chief Public Health Ministry of Health Funafuti Tel. No.: +688 20480/20482 Fax No.: +68820481 n_ ituaso@yahoo.com Email: Mr George Taleo Acting Director of Public Health Ministry of Health Port Vila Tel. No.: +67822512 Fax No.: +67825438 Email: gtaleo@vanuatu.gov.vu

TONGA

TUVALU

VANUATU

WPRlICP1HRF/6.4/00 lIHSD( 1)/2003/IB/2 PageS

2. TEMPORARY ADVISERS

Dr Gillian Durham Deputy Director General - Sector Policy Sector Policy Directorate Ministry of Health P.O. Box 5013 Wellington New Zealand Tel. No.: +644 496 2004 Mobile: +6421 605 093 +6444962340 Fax No.: Email: gillian_durham@moh.govt.nz Dr Safurah Jaafar Deputy Director Primary Health Care Family Health Development Division Ministry of Health Kuala Lumpur Malaysia Tel. No.: +603 2694654 1 Fax No.: +603 26946570 Email: safurah@moh.gov.my

Mr Navi Litidamu Deputy Head of School School of Public Health Fiji School of Medicine Private Mail Bag Suva Fiji Tel. No.: +679 332 1973 Fax No.: +679 332 1107 n.litidamu@fsm.ac.fj Email: Dr David Phillips Head Population and Environmental Health Programme Institute of Environmental Science and Research P.O. Box 50-348 Porirua New Zealand Tel. No.: +644 479 3870 Fax No.: +644 914 0770 Email: dphillips@paradise.net.nz

WPRlICPIHRF/6.4/001lHSD(1 )l200311B/2 Page 6

Dr Vu Xuan Pliu Head Department of Health Economics Ha Noi School of Public Health 138 Giang Vo HaNoi VietNam Tel. No.: +8448452822 ext. 147 +8448452738 Fax No.: Email: vxp@hsph.edu.vn; phu_vx@yahoo.com

Dr Lepani Waqatakirewa Director Primary and Public Health Services Ministry of Health P.O. Box 2223 Government Buildings Suva Fiji Tel. No.: +6793306177 Fax. No.: +6793306163 Email: Iwaqatakirewa@health.gov.fj

3. CONSULTANT

Dr Anthony Lower Team Leader - Pacific Action for Health Project Secretariat of the Pacific Community B.P.DS Noumea-Cedex New Caledonia Tel. No.: +687260179 Fax. No.: +687263818 Email: tonylo@spc.int

4. REPRESENT ATlVES/OBSERVERS

MINISTRY OF HEALTH VANUATU

Dr Timothy Vocor Director Northern Health Care Group Ministry of Health Port Vila

WPRlI CP IHRF16.4/001/HSD(1 )/2003/IB/2 Page 7

Mr Thomas 150m Director Southern Health Care Group Ministry of Health Port Vila

FIJI SCHOOL OF MEDICINE

Professor Sitaleki Finan Head School of Public Health and Primary Care Fiji School of Medicine Private Mail Bag Suva Fiji Fax. No.: +6793321107 Email: s.finau@fsm.ac.fj Dr Narendra Singh Senior Lecturer and Assistant Head of School (Academic) Fiji School of Medicine Private Mail Bag Suva Fiji +679332 1107 Fax No.: Email: n.singh@fsm.ac.fj

SECRETARIAT OF THE PACIFIC COMMUNITY

Dr Mark Jacobs Manager Public Health Programme Secretariat of the Pacific Community Post BoxD5 98848 Noumea Cedex New Caledonia Tel. No.: +687262000 Fax No.: +687263818 Email: markj@spc.int

WPR/ICPIHRF16.4/001IHSD(1 )/200311B/2 Page 8

SECRETARIAT

Dr Graham Harrison Regional Adviser in Health Systems Development WHO Regional Office for the Western Pacific Manila Philippines Tel. No.: +632 528-9806 +632 526-0279/526-0362/521-1036 Fax No.: harrisong@wpro.who.int e-mail: Ms Lorraine Kerse Regional Adviser in Human Resource Development The Office ofthe WHO Representative Level 4, Provident Plaza One Downtown Boulevard 33 Ellery Street Suva Fiji Tel. No.: +6793304-600 Fax No.: +679 3 300-462 Email: kersel@fj.wpro.who.int

ANNEX 2 WORLD HEALTH ORGANISATION MONDIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL

CONSULTATION ON ESSENTIAL PUBLIC HEALTH FUNCTIONS WITH AUSTRALIA, NEW ZEALAND AND PACIFIC ISLAND COUNTRIES Nadi, Fiji 8 to 11 December 2003

WPRlICPIHRF/6.4/001lHSD(1)/2003.1(b) 3 December 2003

ENGLISH ONLY

PROGRAMME OF ACTIVITIES

DAY 1 - Monday, 8 December

0815 -0900 0900 - 1000 1000 - 1030 1030 - 1200

Registration Opening ceremony and group photograph Coffee break Introduction: objectives of consultation, overview of agenda EPHFs - introduction and overview -- Presentation -- Group discussions

1200 - 1330 1330 - 1530

Lunch break Country experience using the EPHF concept -- Presentation from Malaysia, Viet Nam and Fiji -- Group discussions

1530-1600 1600 - 1700 1830

Coffee break Group discussions continued Reception

WPRlICP/HRF/6.4/001lHSD(1)/2003.1(b) Page 2

DAY 2 - Tuesday, 9 December

0900- 0915 0915 - 1000

Summary of previous day's discussions Guidelines, tools and indicators to help Member States evaluate, monitor and strengthen public health -- Presentation -- Group discussions

1000 -1020 1020 - 1200 1200 - 1330 1330 - 1530

Coffee break Group discussions continued Lunch break Plenary Reorienting health professionals, managers, policy-makers and government institutions in line with EPHFs -- Presentation

1530 - 1600 1600 -1700

Coffee break Group discussions

DAY 3 - Wednesday, 10 December

0900 - 0915 0915 - 1000 1000 -1020 1020 -1200 1200 - 1330 1330 - 1500 1500-1530 1530 - 1700

Summary of previous day's discussions Plenary Coffee break Strengthening and defining the role of the department/ministry of health Lunch break Group discussions continued Coffee break Plenary

WPRlJCPIHRF'l6.4/00 lIHSD( 1)/2003.1(b) Page 3

DAY 4 - Thursday. 11 December 0900 - 0915 0915 -1000 Summary of previous day's discussions Review of the nine EPHFs Group discussions 1000 - 1020 1020 - 1200 Coffee break Competencies for public health practice Group discussions 1200 - 1330 1330 - 1500 1500 - 1530 1530 Lunch break Finalize recommendations Coffee break Closing ceremony

ANNEX 3

WORLD

HEALTH

ORGANISATION MONDIALE DE LA SANT~

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL

CONSULTATION ON ESSENTIAL PUBLIC HEALTH FUNCTIONS WITH AUSTRALIA, NEW ZEALAND AND PACIFIC ISLAND COUNTRIES Nadi, Fiji

WPRlI CP IHRF16.4/001lHSD(1 )/2003 5 December 2003

ENGLISH ONLY

8 to 11 December 2003

LIST OF DOCUMENTS

WPRlICP/HRF/6.4/00 IIHSD(I)/2003.1 WPRlICPIHRF/6.4/00 lIHSD(I)/2003.1a WPRlICP/HRF/6.4/00 IIHSD(I)/2003.1 b WPRlICP/HRF/6.4/001IHSD(I)/2003/IB/I

Provisional Agenda Tentative Timetable Programme of Activities General Information Information Bulletin No. I List of Participants, Temporary Advisers, Representatives/Observers, Consultants and Secretariat Information Bulletin No.2 Handouts

WPRlICP/HRF/6.4/001IHSD(I)/2003IIB/2

WPRlICP/HRF/6.4/001IHSD(I )/2003/INF.l1

Background paper for agenda item 1: Consider and discuss the nine proposed essential public health functions developed for the Western Padfic Region, and methods that were used to evaluate these functions in the three country case studies The 9 Essential Public Health Functions. tasks and practices developed for the three-country study in the Western Pacific Region Background paper for agenda item 2: Identify the types of guidelines, tool and indicators, based on EPHF that would be useful in assisting Members States to evaluate, monitor and strengthen their public health infrastructures

WPRlICP/HRF/6.4/001IHSD(I)/2003/INF.l2

WPRlICPIHRF/6.4/00 lIHSD(I )/2003/INF.l3

WPRII CPIHRF/6.4/00 lIHSD(l )/2003 Page 2

WPRlICPIHRF/6.4/00 IIHSD(l )/2003/INF.l4

Background paper for agenda item 3: Identify approaches to promote the reorientation of health professionals, managers, policy makers and govemment institutions towards public health, in line with the development of essential public health functions Background paper for agenda item 4: Discuss ways in which EPHFs can strengthen and define the central role of the ministry/department of health

WPRlICPIHRF/6.4/001IHSD(I)12003/INF.l5

ANNEX 5

WORLD

HEALTH

ORGANISATION MONDIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL

CONSULTATION ON ESSENTIAL PUBLIC HEALTH FUNCTIONS WITH AUSTRALIA, NEW ZEALAND AND PACIFIC ISLAND COUNTRIES 8 to 11 December 2003 Nadi, Fiji

WPRlICPIHRF16.4/00 IIHSD(I )/2003/INF'/1 20 November 2003

ENGLISH ONLY

Background paper for agenda item 1: Consider and discuss the nine proposed essential public health functions developed for the Western Pacific Region, and methods that were used to evaluate these functions in the three country case studies. Prepared by: Dr Graham Hamson

;

Paper overview This paper concisely outlines the basis for the development of Essential Public Health Functions (EPHFs) in the Western Pacific Region of WHO, lLld the framework that has been developed. For ease of reference, the EPHFs, tasks and practices have been separately listed in the accompanying paper WPRlICPIHRF16.4/001IHSD(1)/ 2003/INF.l2.

Introduction A central issue that needs consideration when trying to strengthen the public health infrastructure (systems and services) is: what is public health? There are many broad definitions of public health, for example: "Public health is the science and art of preventing disease, prolonging life, and promoting health through orgarnzed efforts of society" [1]. Public health is "the art of applying science in the context of politics so as to reduce inequalities in health while ensuring the best health for the greatest number" [2). i

Regional Adviser for Health Systems Development, Regional Office for the Western Pacific, WHO, Manila

WPRII CPIHRF16.4/00 lIHSD(1 )/20031INF .11

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Alternatively, public health may be described as a number of broad core areas of public health work: disease control, injury prevention, health protection, healthy public policy, promoting health and equitable health gain, and combating threats to public health. Public health might also be described in terms of "outcomes": raising health status and quality oflife; reducing health inequalities; increasing safeguards for the public's health; reducing the acute and chronic disease burden. Although useful in different ways, these very broad definitions and descriptions do not necessarily help to define more clearly and comprehensively what public health is about in a way that would help relevant authorities to identify and ensure that a comprehensive range of activities is put in place, to cover all of what public health is or should be about. Alternatively, the range of public health could be defined by identifying the public health services that are currently delivered. However, while identifying and evaluating current services is important for improving the quality of those services, this does not result in a more fundamental review of what services should be provided in the first place. Using a list of current services also pre-supposes that the grouping of activities into individual services is already in its most efficient and effective form. There are also problems with lists of services becoming inflexible and more difficult to change over time. It is, however, useful to bear in mind a broad classification of the types of services that may contribute to the implementation of EPHFs [3]: • • • Population-based public health programs (for example, vector control, population based health promotion activities) Personal preventive services (for example, immunization) Personal treatment services of public health significance \lVi example, treatment of tuberculosis or sexually transmitted infections).

Because of these difficulties, WHO, in the Western Pacific Region, devised a project that attempted to improve the way in which public health could be defined more systematically, and yet be generic and maintain a degree of flexibility, that would assist with strengthening public health and the services provided in each country. The project drew on a number of international developments and utilised an approach of "Essential Public Health Functions" (EPHFs), which have been described by Yach [4] as: " ... a set of fundamental activities that address the determinants of health, protect a population's health, and treat disease. These public health functions represent public goods, and in this respect governments would need to ensure the provision of these essential functions, but would not necessarily have to implement and [mance them. They prevent and manage the major contributors to the burden of disease by using effective technical, legislative, administrative, and behaviourmodifying interventions or deterrents, and thereby provide an approach for intersectoral action for health ....... This approach stresses the importance of numerous different public health partners. Moreover, the need for flexible, competent state institutions to oversee these cost-effective initiatives suggests that the institutional capacity of states must be reinforced."

It is important to note that the EPHFs cover all sectors, and not just the 'health sector',

although the health sector is certainly one of the more important players in terms of making sure most of these activities are delivered by some means. In addition, the EPHF concept also covers public health activities of both the public and private sectors.

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The EPHF framework

In developing this project, various sets of essential pub[' .'ealth functions were considered, including: the WHO Delphi study [5]; the Ulilted States of America (USA) [6]; the Centers for Disease Control and Prevention, Centro Latino Americano de Investigacion en Sistemas de Salud and the Pan American Health Organization [7t; and Australia [9]. The components of the framework developed for the EPHFs as part of this project in the Western Pacific Region can be summarised: • • • Nine EPHFs were developed (drawing on the other work identified above); each EPHF has an outcome statement. A set of tasks are identified for each EPHF. Each task is then also defined in terms of a set of practices. These practices are the collective processes through which public health inputs (for example, the workforce, information, etc) are applied to deliver the functions, and they result in outputs (programs and services) intended to improve health status. The grouping into various services is dependent on the context of each country.

•

In addition, the EPHFs (including the tasks, practices and grouping into services) must be delivered in a relevant context of governance and stewardship with consideration of appropriate preconditions, links, relationships and supports to be effective.

This framework is summarised in Figure 1. More technical discussion on the background of the key components of the framework is contained in reference 10. Figure 1: EPHF framework

Governance and Stewardship Critical I'inksandrelatlonshlps ~

P Core work of public health j .

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...

9 Essential Public Health Functions

. "

•

key tasks J

c c e I, . . e s I- . s I

r a c t i

'i.

S ,e ·r I v i

Public health outcomes

...

~ I ThIS Instrument has since been updated (refer reference 8).

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WPR/lCP IHRF16.4/001lHSD(1 )/2003fINF.ll Page 4

The nine EPHFs derived for this study, the associated outcome statements, tasks and practices are described in the accompanying paper, WPRJICPIHRF/6.4/001IHSD(I)1 2003/INF.l2. This accompanying paper also includes a section that defines the different practices. The EPHF framework recognises that the public health activities and services are not provided in isolation. Thus, if a comprehensive understanding or evaluation of the EPHFs is to be developed, the context of the EPHFs and relevant organisations must be considered. This includes their stewardship and governance, a supportive institutional environment (including ownership arrangements, leadership and management of the organization, and even factors such as the population size covered), as well as a number of preconditions, critical links and relationships that must be in place for the effective and efficient implementation ofEPHFs, as shown in Figure 2. In particular, implementation of EPHFs cannot occur without good quality information-driven relationships that fuel links within and between public health organizations, \',_ )n and between relevant organizations in the health sector, between sectors, between providers and individuals and communities, and amongst individuals and communities_ Figure 2: Links and relationships for effective delivery of EPHFs

Assessing and understanding relevant preconditions, critical links, relationships and supports are an important part of both (i) assessing the nature ofEPHFs in place, as well as (ii) strengthening the public health infrastructure. The following aspects, therefore, warrant consideration: • preconditions/criticallinks/relationships that should be in place for each function, that are necessary to ensure that: • • the function can be effectively carried out, and effective coordination with other relevant services and stakeholders (for example, for the authorization of exercise of legislative powers, or for specialized advice, or avoiding certain situations of conflict of interest);

•

the type of training necessary (in broad terms) to successfully undertake each function; and

ANNEX 4

OPENING REMARKS BY DR CHEN KEN, WHO REPRESENTATNE FOR SOUTH PACIFIC, FOR DR SHIGERU OMI, REGIONAL DIRECTOR, WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC FOR THE CONSULTATION ON ESSENTIAL PUBLIC HEALTH FUNCTIONS WITH AUSTRALIA, NEW ZEALAND AND PACIFIC ISLAND COUNTRIES. 8 DECEMBER 2003, NADI, FIJI DISTINGUISHED GUESTS, LADIES AND GENTLEMEN, On behalf of the World Health Organization's Regional Director for the Western Pacific Region, I would like to welcome you all to Nadi to participate in the consultation on essential public health functions with Australia, New Zealand and Pacific island countries. I am glad that so many of you could come to this consultation, despite your busy schedules. Public health is a core element of every government's attempts to improve and promote health. Unfortunately, there is evidence that current public health systems and services struggle to cope with current public health issues and demands. This problem applies to traditional public health areas, such as hygiene, sanitation and communicable disease control, with SARS being the most apparent recent example of this. However, this problem also applies to newer areas of public health, such as the effects of globalization, migration and the use of new technologies. Public health is also central and critical to the work of WHO around the world, and is the foclls of our collaboration with Member States. In recognition of this, the Western Pacific Regional Office has undertaken work on essential public

health functions. The aim of this work is to help governments identifY and strengthen those public health activities that are essential for each country and that need to be provided by some means. WHO's work in the Region has been built on a variety of other work undertaken around the world. At this meeting, you will be introduced to the concept and provided with some of the detail, including the work that has been undertaken in the Region to date. I hope that this meeting will provide you with an opportunity to constructively discuss and debate many aspects of public health with your friends and colleagues, and stimulate ideas of what might be possible and useful to strengthen public health, to help you in your day-to-day work, and to use for your country's benefit over the longer term.

Importantly, WHO will also be able to get your input as a result oithis consultation, to look at what guidelines, tools and indicators would be useful to assist Member States to evaluate, monitor and strengthen their public health infrastructure and services. We will also discm:. eas and approaches to promote the

reorientation of health professionals, managers, policy-makers and government institutions towards public health, in line with the development of essential public health functions. Finally, the meeting is also a forum to discuss ways in which the concept of essential public health functions can be used to strengthen and define more clearly the central role ofthe ministry or department of health. All of these aspects will be critical if we

are to work together and look at ways of strengthening our public health infrastructure and systems for the challenges of the future. I wish you well in your discussions, and I hope you have a stimulating and interesting time during this consultation meeting. Thank you.

WPRlICPIHRF/6.4/00 IIHSD( 1)120031INF.l1 Page 5

•

other relevant factors, such as geographical location (in broad tenns), and in a few cases it may be necessary to identify separate sub-components necessary to ensure good delivery of that function.

Various supports must also be in place for the effective functioning and delivery of EPHFs. These supports include infonnation (of a wide variety, including the appropriate analysis of data, and that it is accessible at the right time and the right place [11]), and relevant laboratory and pharmaceutical services. Distribution of EPHFs It is important to recognize that the delivery of each EPHF, task or practice is likely to be different between different health service levels (eg central, provincial, district, etc). Therefore, any evaluation of EPHFs or any proposal to strengthen EPHFs will need to take into account the different health service levels and their expected role in terms of delivering/undertaking the appropriate public health services and activities. This is illustrated in Figure 3. Figure 3: Distribution of an EPHF, task or practice between different health service levels

Health Service Level: 1

Degree of EPHF, task or practice undertaken

2 3

4 Equal degree at all health service levels

~ Highest degree at the central health service level Highest degree at peripheral health service levds

~ Highest degree at the middle health service levels

Interpretation:

EPHFs: What is included and what is not? EPHFs focus on activities relevant to public health. The EPHFs are broad, and act as a framework for all areas of government, not just those areas of public health which may officially lie within the jurisdiction of the department/ministry of health. They can encompass activities that are undertaken in many areas of government as well as the private sector. It is important to note that the EPHFs cover not only traditional public health activities and areas of work, but also such issues as access to health care and the regulation and overall monitoring of the safety of clinical services and health professionals, equity in the use of health services, the quality of those clinical services, and preparing for clinical and public health services' response to disasters.

WPRlI CPIHRF16.4/00 I/HSD(l )/2003/INF./1

Page 6 However, as the focus of EPHFs is on public health, it is not intended that these nine functions should include all aspects of all services delivered by the health sector. Specifically, the two key areas which are not include r1 • ithin the EPHF framework are: • Diagnostic and clinical services (including direct management, service planning and human resource development) that are not related to treating diseases of public health significance. The EPHFs do include clinical services needed for the treatment of diseases of public health significance, for example tuberculosis, and the delivery of immunization for children. The inclusion of other activities can vary from country to country (for example, many would probably choose to include maternal and child health, as well as a number of other primary health care activities within EPHFs). EPHFs tend to exclude, for example, the delivery of surgical interventions in hospitals (but the safety and quality framework in which those services are delivered is included, as is the monitoring of access to those services). Overall policy and mechanisms for public financing. Methods by which funds are raised by governments for public sector activities are usually the responsibility of ministries of finance. Raising funding is not a public health function, per se. However, the analysis of effects of the different methods of raising those public funds (for example, from an equity and access to services perspective) is an important part ofthe EPHF framework. So, too, is advocacy by relevant agencies within the health sector for appropriate levels and mechanisms of financing. In addition, the EPHFs do include the issue of advising on priorities of publicly-funded health services and the allocation of public ftmds. The only area in which funding is included is in relation to identifying adequate sources of funding for research relating to public health (this wa~ included because it was recognized that most health systems provide very little public funding for public health research).

•

Relationship to Primary Health Care Structurally, EPHFs have been considered an integral part of primary health care at least since the Alma-Ata International Conference on Primary Health Care, jointly sponsored by the World Health Organization and the United Nations Children's Fund in 1978 [12]. Unfortunately, this structural arrangement does not ensure the sustainability of these functions. The Asian Development Bank has noted th~t more than 80 percent of essential interventions and nearly 70 percent of desirable intervel1tions focus on primary health care, but countries in the region spend on average less than 10 percent of their health-care resources on primary care [13]. \

Risks to the sustainability ofEPHFs when integrated in primary health care include a narrow view of health promotion and competing priorities [14]. In developed countries particularly, primary care professionals tend to equate health promotion with health education rather than the encompassing social, policy, and skill development focus of health promotion as expressed in the Ottawa Charter for Health Promotion [13]. Ashton [14] cites survey evidence to remind us that no matter how enthusiastic some primary care professionals are about public health, the reality is that the response rate to surveys of primary care professionals on public health in primary care are low, and of those that do respond, few are undertaking preventive work and usually attribute this to lack of time.

WPRII CPIHRF16.4/001IHSD(1 )/2003/INF./1 Page 7

Whether or not EPHFs are integrated structurally in primary health care, the links and interacting relationships, described broadly above, between personal preventive and treatment services are important for the sustainable delivery ofEPHFs. Who should be responsible for EPHFs? Who should take overall responsibility for EPHFs? The EPHFs represent public goods, and in this respect, governments as a whole need to ensure they are provided, although actual provision of these activities can be undertaken through a mixture of public, private and nongovernmental organizations and community groups, depending on what is most relevant for the country. The EPHFs are broad, and act as a framework for all relevant parts of government which have jurisdiction for overseeing or implementing different public health activities or aspects, not just the department/ministry of health. It is possible to consider many of these key functions comprehensively only in communities where the rule of '.!W exists, there is no substantial civil or political unrest and the community is not at war. Who should be responsible for financing EPHFs? Although governments need to ensure that all EPHFs are provided, they do not always have to implement and finance them directly. Having said this, it is very important to recognize the nature of the EPHFs, for they are public goods, and individuals may be reluctant to pay directly for public health services because not all benefits accrue to them personally. Therefore, although private and nongovernmental organizations may assist in delivering these essential functions, governments may have to consider financing the greater part of the EPHFs, or at least to ensure that they are adequately financed from funds collected from society (for example, from funds already collected through a social health insurance or other relevant scheme). In some cases, the EPHFs are central to governments' stewardship and governance roles with respect to health, and it would be inappropriate for others to finance or provide core elements of these functions. lli

Using EPHFs to evaluate the current system

It is important to understand how an EPHF approach can contribute to national public health development. A useful first step in this is the evaluation of current EPHF performance. In the case of programmes, this task is relatively easy, however the situation is more complicated in the case of EPHFs that do not correspond to programmes or are not organized as well-defined functional units. However, for practical purposes EPHFs can be examined from the perspective of three different structural components, namely:

• •

Specific practice of the essential public health function: activity at a local or central level to underpin a range of national public health goals Practice in Public Health Programmes: e.g. environmental health, communicable disease control etc. Note: some of these programmes, or parts of them, constitute iii

Contributed by Dr David Phillips

WPRlICP/HRF/6.4/001lHSD(1)12003IINF.ll Page 8

an essential public health function, e.g. epidemiological surveillance (EPHF 2), health promotion (EPHF 3). • Practice incorporated into others areas of health care and/or other organisations: particularly personal health care services at the primary levellNGO projects etc.

The methods and tools used for evaluation will depend on the breadth and depth of analysis required and that will reflect individual country settings and priorities.

References I.

3. 4. 5. 6. 7.

8. 9. 10.

11.

Committee oflnquiry into the Future Development of the Public Health Function (1988). Public Health in England. HMSO: London. World Health Organization (1998). The World Health Report 1998: Life in the 21st century, a vision for all. Geneva. Swan M, Zwi A (1997). Private practitioners and public health: close the gap or increase the distance? London School of Hygiene and Tropical Medicine: London. Yach D (1996). Redefining the scope of public health beyond the year 2000. Current Issues in Public Health, vol 2: p247 - 52. Bettcher D, Sapirie S, Goon EHT (1998). Essential public health functions: results of the international Delphi study. World health statistics quarterly, vol 51: p44 - 55. Department of Health and.Human Services (1997). The public health workforce: an agenda for the 21st century. Washington DC. Centers for Disease Control and Prevention, Centro Latino Americano de Investigaciones en Sistemas de Salud, Pan American Health OrganizationIWorld Health 0rganization (2000). Public health in the Americas: national level instrument for measuring inoential public health functions. Washington DC. Pan American Health Organization (2002). Public Health in the Americas: Conceptual Renewal, Performance Assessment, and Bases for Action. Washington DC. National Public Health Partnership Group (2000). National Delphi study on public health functions in Australia. Victoria. World Health Organization. Essential Public Health Functions: a three-country study in the Western Pacific Region. Manila: World Health Organization, Regional Office for the Western Pacific, 2003. World Health Organization (1994). Information support for new public health action at distl'ict level: report of a WHO Expert Committee. Geneva. World Health Organization, United Nations Children's Fund (UNICEF) (1978). Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. World Health Organization: Geneva. Asian Development Bank (1999). Health sector reform in Asia and the Pacific: options for developing countries. Manila. Ashton J (1990). Public health and primary care: towards a common agenda. Public Health, vol 104: p. 387 - 98.

12.

13.

14.

WORLD

HEALTH

ORGANISATION MONDIALE DE LA SANTE

ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL

CONSULTATION ON ESSENTIAL PUBLIC HEALTH FUNCTIONS WITH AUSTRALIA, NEW ZEALAND AND PACIFIC ISLAND COUNTRIES 8 to 11 December 2003 Nadi, Fiji

WPRlICP/HRF/6.4/001IHSD(1)/2003IINF.l2 20 November 2003

ENGLISH ONLY

The 9 Essential Public Health Functions, tasks and practices developed for the three-country study in the Western Pacific Region[1]

The Framework: Governance and S.tewardship Critical links and relationships ~ ~

Core work of public health

!"'"

Essential Public Health Functions • key tasks

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L-__~====:1======~J~/- ~~I.~_____ ~_____~" L Commonly described areas Commonly expressed outcomes: of public health work: • Disease control • Injury prevention • Health protection • Healthy public policy • Promoting health and equitable health gain • Combating threats to public health Public health services can be broadly grouped into: • Population-based public health services • Personal preventive services • Personal treatment services of public health significance Raise health status and quality of life Reduce health inequalities Increase safeguards for the public's health Reduce acute and chronic disease burden

S e a r c v t ~ i i c c e e s s

P r

Public health outcomes

yi~ I"~

•

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FUNCTION 1: Health situation monitoring and analysis Outcomes The outcomes of this function are the measurement, monitoring and analysis of changes in health status, including quality of life and health inequalities, and the acute and chronic disease burden. The function results in confidence that safeguards exist for the protection of the public's health and provides early warning ofproblerns. Tasks 1.1 Assess health status of the country, both accurately and on-going, for larger administrative units within the cotmtry, and for specific groups that are of higher risk for health threats than the general population. Practices: assess; analyze; set priorities; evaluate; communicate; collect and use evidence. Analyze, in addition to (1), trends in sociodemographic variables, mortality, morbidity, risks and hazards (personal and environmental), barriers to access to personal preventive services and personal treatment services ofpublic health significance; and coverage of population-based public health services. Practices: analyze. Identify current and potential threats to health. Practices: assess~

FUNCTION 2: Epidemiological surveillance/disease prevention and control Outcomes The outcomes of this function contribute to improving health status and the quality of life, reducing health inequalities, safeguarding the public's health and reducing the burden of disease. Tasks 2.1 Conduct surveillance of outbreaks and patterns of communicable and noncommunicable diseases, injuries, and exposure to enviromnental agents harmful to health. Practices: assess; investigate; analyze; develop plans; manage resources; evaluate; communicate; collect and use evidence; fnsure compliance.

1.2

2.2 Investigate disease outbreaks and injury patterns, and the associated risks and hazards. Practices: set priorities; negotiate; develop plans; manage resources; implement; communicate.

2.3 Undertake case finding, diagnosis and treatment of diseases of public health significance, such as tuberculosis. Practices: investigate; negotiate; manage patients; communicate; ensure compliance. 2.4 Access information and support services for better management of health problems of interest. Practices: assess: negotiate; collect and use evidence; communicate.

1.3

investigate; analyze;

communicate; collect and use evidence. 1.4 Periodically assess health services needs (andlor targeted assessments). Practices: assess; analyze; evaluate; collect and use evidence. Identify resources and assets (in communities and in other sectors) to support public health. Practices: investigate; assess. Profile health status - the production and distribution of a health status profile including 1-5 above. Practices: analyze; communicate; collect and use evidence. Manage information - development of technology, expertise, and methods for management, analysis, quality control, and communication of information to all those with responsibilities for improving the public health. Practices: develop plans; manage; implement; evaluate; collect and use evidence.

2.5 Respond rapidly to control outbreaks and emerging specific health problems or risks. Practices: assess; analyze; negotiate; set priorities; develop plans; manage; collect and use evidence; ensure compliance. 2.6 Implement mechanisms to improve surveillance systems and disease prevention and control. Practices: assess; analyze; negotiate; develop plans; implement: evaluate; communicate.

1.5

1.6

1.7

1.8 Integrate information systems, by collaborating within the public health system, with other parts of the health sector, and with other sectors, including the private sector. Practices: negotiate; communicate; advocate;

integrate. i

Country-specific interpretation of that part of this

task

specified in italics.

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FUNCTION 3: Development of policies and planning in public health Outcomes The outcomes of this function are the development of policies and plarming for the improvement of health status and quality of life, reducing health inequalities, safeguarding the public's health, and reducing the burden of disease. Tasks 3.1 Develop policy and legislation to guide the practice of public health Practices: analyze; advocate; negotiate; set priorities; develop plans; collect and use evidence; communicate. Develop and evaluate plans to promote and protect public health. Practices: assess; analyze; negotiate; integrate; set priorities; develop plans; manage; evaluate; communicate.

FUNCTION 4: Strategic management of health systems and services for population health gl,lin Outcomes The outcomes of this function contribute to implementation of strategies to improve health status and the quality of life, reduce health inequalities, safeguard the public's health, and reduce the burden of disease. Tasks

4.1

Promote and evaluate effective access by all citizens to the health services they need. Practices: assess; investigate; evaluate. Resolve and reduce inequities in the use of health services by multisectoral collaboration that facilitates working with other agencies and institutions. Practices: advocate; integrate; implement; evaluate. Overcome barriers to access to necessary health services by individuals and communities by population-based public health actions. Practices: investigate; develop plans; integrate; implement; evaluate. Facilitate the linkage of vulnerable groups to health services Practices: advocate; negotiate; integrate; implement; evaluate. Develop competence in evidence-based decisionmak.lg that incorporates resource management, leadership capacity, and effective communication. Practices: negotiate; set priorities; manage; communicate. Advise on priorities of publicly funded health services. Practices: analyze; set priorities; negotiate; communicate; collect and use evidence. Use evidence on safety, effectiveness and cost effectiveness to assess the utility of health technology and interventions. Practices: assess; evaluate; collect and use evidence; communicate. Manage public health to build, implement, and evaluate organized initiatives to address public health problems. Practices: manage; develop plans; integrate; implement; evaluate; set priorities. Prepare for disaster and emergency response by the health system. Practices: assess; negotiate; integrate; set priorities; develop plans; implement; communicate; ensure compliance.

4.2

3.2

4.3

3.3 Review and update regulatory frameworks, policy, and their implementation, regularly and systematically in the light of health status and assessments of health needs. Practices: assess; set priorities; develop plans; evaluate; collect and use evidence. 3.4 Advocate for population-based perspectives in health services policy and the development of health sector regulation. Practices: advocate; negotiate; communicate; collect and use evidence. 3.5 Develop and track measurable indicators of health. Practices: assess; investigate; analyze; implement; evaluate. 3.6 Evaluate jointly with relevant health care systems so as to plan and to define policies regarding personal preventive and treatment services. Practices: advocate; negotiate; develop plans; evaluate; collect and use evidence; communicate.

4.4

4.5

4.6

4.7

4.8

4.9

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FUNCTION 5: Regulation and enforcement to protect public health Outcomes The outcomes of this function contribute to the development and compliance with regulation that improves health status and the quality of life, reduces health inequalities, safeguards and protects the public's health, and reduces the burden of disease. Tasks 5.1 Promulgate and implement laws and regulations in public health. Practices: investigate; negotiate; coltect and use evidence; communicate; ensure

FUNCTION 6: Human resources development and planning in public health Outcomes The outcomes of this function provide the workforce to improve health status and the quality of life, reduce health inequalities, safeguard the public's health, and reduce the burden of disease.

Tasks

6.1

Assess, perform and maintain an inventory of the human resource base including the professional attributes and distribution. Practices: assess; investigate; analyze; evaluate. Project workforce requirements in terms of quantity and quality. Practices: develop plans; set priorities; communicate. Ensure adequate human resource base for public health activities. Practices: advocate; manage; implement. Ensure workers are adequately educated and trained wi th demonstrable certification and recertification. Practices: evaluate; ensure compliance. Coordinate between educational institutions and the workforce, with employers and employees, in the design and delivery of training programs. Practices: negotiate; integrate; communicate; develop plans; implement. Promote and encourage continuing professional education. Practices: negotiate; communicate; advocate. Monitor and evaluate education and training programs. Practices: advocate; manage; implement

compliance. 5.2 Review, develop and update regulations in public health and develop capacity to regulate. Practices: assess; set priorities; develop plans; manage; collect and use evidence. Ensure enforcement of regulations and develop capacity for enforcement. Practices: assess; analyze; manage; collect and use evidence; communicate. Assess and promote compliance Practices: assess; investigate; analyze; advocate; negotiate; integrate; communicate; collect and use evidence; ensure compliance.

6.2

6.3

5.3

6.4

5.4

6.5

6.6

6.7

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FUNCTION 7: Health promotion, social participation and empowerment Outcomes The outcomes of this function make communities healthier by advocating for health and empowering citizens through access to relevant, high quality and effective information.

FUNCTION 8: Ensuring the quality of personal and population-based health services Outcomes The outcomes of this function ensure the quality of personal" and population based health services to improve health status and the quality oflife, reduce health inequalities, safeguard the public's health, and reduce the burden of disease.

Tasks 7.1 Contribute to improving the capacity and capability of communities and decreasing their vulnerability to risks and damages to health. Practices: develop plans; set priorities; implement; communicate; evaluate; manage; collect and use evidence; negotiate; advocate. Create supportive environments to make the healthy choices the easy choices, by building coalitions, promoting relevant laws and policies, working intersectorally to make health promotion programs more effective, and advocating with government authorities in relation to health priorities. Practices: advocate; negotiate; integrate; communicate; develop plans; collect and use evidence; implement. Empower citizens to change lifestyles and play an active role in changing community norms about particular behaviors to achieve permanent, large-scale behavior change. Practices: advocate; negotiate; communicate; set priorities; coHect and use evidence. Facilitate and convene partnerships among groups and organizations to promote health. Practices: advocate; communicate; negotiate; integrate; manage. Communicate through social marketing and targeted media communications. Practices: advocate; communicate. Provide accessible health information resources at community levels. Practices: assess; communicate; develop plans; manage; implement; evaluate.

Tasks 8.1 Define appropriate standards for the quality of both personal and population-based health services. Practices: assess; investigate; analyze. Develop models of quality evaluation. Practices: set priorities; develop plans. Id~nlify

8.2 8.3

7.2

valid and reliable measurement instruments to monitor quality. Practices: investigate; analyze; evaluate.

8.4

Monitor and ensure safety and ongoing improvement in quality. Practices: develop plans; manage; implement; evaluate.

7.3

7.4

7.5

7.6

Country-specific interpretation for the part of this function specified in italics

WPRlICP/HRF/6.4/001IHSD(1 )/2003/INF.l2 Page 6

FUNCTION 9: Research, development and implementation of innovative public health solutions Outcomes The outcomes of this function contribute to Umovative ways to improve health status and the quality of life, reduce health inequalities, safeguard the public's health, and reduce the burden of disease.

DEFINITIONS OF 'PRACTICES' Advocate is to use a combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or program [2]. Analyze is to examine in detail the detenninants of identified health needs [3,4]. Assess is to undertake the regular systematic collection, assembly, analysis, and dissemination of information on the health of the community [5).

Tasks

9.1

Develop a public health research agenda. Practices: investigate; analyze; set priorities; develop plans; communicate; collect and use evidence. Identify adequate sources of research funding. Practices: communicate; develop plans; manage. Encourage cooperation and joint approaches between public health agencies and organizations to address funding and the conduct 0 f research for the research agenda. Practices: communicate; manage; negotiate; integrat~

Collect and use evidence - refer Use evidence Communicate is the practice of conveying information or evoking understanding in health issues[3). Develop plans is the practice of formulating methods by which priority health needs are to be addressed [3,4]. Ensure compliance with regulation is the practice of making certain acquiescence to regulation [3). Evaluate is the assessment of the effect that health services or programs have on the population's health [3,4). Implement is the practice of putting into effect a health policy or program [3). Integrate is the practice by which different partners or stakeholders may have to give up some of their authority and prerogatives as they converge their efforts to improve health, but they retain their identity and specificity [6). Investigate is to undertake a systematic inquiry into the occurrence of health effects and health hazards in the community [3,4). Manage (resources) is the practice of planning, organizing, staffing, and controlling the work and financial resources needed to undertake essential public health functions [7]. Manage (patients) is the practice of planning, organizing and controlling the personal preventive care and personal treatment of patients whose illnesses are of public health significance. Negotiate is to confer with others in order to reach a compromise or agreement [3). Set priorities is the practice of choosing which health needs have prior claim to consideration when there is a gap between the availability of resources and the demand for health services [3,4, 8) Use evidence is the practice of conscientiously, explicitly and judiciously using current best evidence in making decisions related to public health [9].

9.2

9.3

9.4

Ensure appropriate ethical safeguards for public health research. Practices: develop plans; communicate; implement; ensure compliance Develop processes for dissemination of research findings. Practices: communicate; negotiate; develop plans; implement; manage Encourage participation of public health workers in research at all levels. Practices: communicate; develop plans; set priorities Develop innovative programs to address the identified problem. Practices: develop plans; manage; implement

9.5

9.6

9.7

, References 1.

WPRlICPIHRF/6.4/001lHSD(1)/2003IINF.12 Page 7

2. 3. 4.

6. 7. 8. 9.

World Health Organization. Essential Public Health FU/H .•..Jns: a three-country study in the Western Pacific Region. Manila: World Health Organization, Regional Office for the Western Pacific, 2003 Nutbeam D (1997). Health promotion glossary. World Health Organization: Geneva. Allen R ed (1990). The Concise Oxford Dictionary of Current English. Eighth ed. Clarendon Press: Oxford. Richards T, Rogers JJ, Christensen GM, Miller CA, Taylor MS, Cooper AD (1995). Evaluating local public health performance at a community level on a statewide basis. J Public Health Management Practice, vol 1(4): p70 - 83. Miller C, Moore KS, Richards TB, Monk JD (1994). A proposed method for assessing the performance of local public health functions and practices. American Journal ofPublic Health, vol 84(11): pl743 - 9. Boelen C (1999). Towards Unity for Health. World Health Organization: Geneva. Breckon D (1997). Managing health promotion programs: leadership skills for the 21st century. Gaithersburg, Maryland: Aspen Publishers Inc. Ham, C. (1996). Priority setting in health. In Janovsky Ked. Health policy and systems development. World Health Organization: Geneva. Sackett D, Rosenberg W, Gray H, Haynes R, Richardson W (1996). Evidence based medicine: what it is and what it isn't. EMJ, vol 312(7023): p71-2.

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Technical Documents

Date d'adoption 31 décembre 2003

Source Organisation mondiale de la santé